N.H. Admin. Code § He-P 803.28

Current through Register No. 45, November 7, 2024

Section He-P 803.28 - Emergency Preparedness

(a) Each licensee shall have an individual or group, known as an emergency management committee, with the authority for developing, implementing, exercising, and evaluating the emergency management program.

(b) The emergency management committee shall include the licensee's administrator and others who have knowledge of the facility and the capability to identify resources from key functional areas within the facility and shall solicit applicable external representation, as appropriate.

(c) An emergency management program shall include, at a minimum, the following elements:

(1) The emergency management plan, as described in (d) and (e) below;

(2) The roles and responsibilities of the committee members;

(3) How the plan is implemented, exercised, and maintained; and

(4) Accommodation for emergency food and water supplies.

(d) The emergency management committee shall develop and institute a written emergency preparedness plan (plan) to respond to a disaster or an emergency.

(e) The plan in (d) above shall:

(1) Include site-specific plans for the protection of all persons on-site in the event of fire, natural disaster, or severe weather and human-caused emergency to include, but not be limited to, missing residents and bomb threat;

(2) Be approved by the local emergency management director and reviewed and approved, as appropriate, by the local fire department;

(3) Be available to all personnel;

(4) Be based on realistic conceptual events;

(5) Be modeled on the Incident Command System (ICS) in coordination with local emergency response agencies;

(6) Provide that all personnel designated or involved in the emergency operations plan of the facility shall be supplied with a means of identification, such as vests, baseball caps, or hard hats, which shall be worn at all times in a visible location during the emergency;

(7) Develop and implement a strategy to prevent an incident that threatens life, property, and the environment of the facility;

(8) Develop and implement a mitigation strategy that includes measures to be taken to limit or control the consequences, extent, or severity of an incident that cannot be prevented;

(9) Develop and implement a protection strategy to protect life, property, and the environment from human caused incidents and events and from natural disasters;

(10) For (7) -(9) above, incorporate the findings of a hazard vulnerability assessment, the results of an analysis of impact, program constraints, operational experience, and cost-benefit analysis to provide strategies that can realistically be implemented without requiring undue expenses to the -licensee;

(11) Conduct a facility-wide -walk-through and review, to include the property that the licensee is located on, to determine the status of hazards that may be incorporated into the prevention, protection, and mitigation strategies and to determine the outcome of prior strategies at least annually;

(12) Include the licensee's response to both short-term and long-term interruptions in the availability of utility service during the disaster or emergency, including establishing contingency plans for continuity of essential building systems or evacuation to include the following, as applicable:

a. Electricity;

b. Potable water;

c. Non-potable water;

d. HVAC;

e. Fire protection systems;

f. Fuel required for building operations, to include fuel loss, fuel spill, and fuel exposure that creates a hazardous incident;

g. Fuel for essential transportation, to include fuel loss, fuel spill, and fuel exposure that creates a hazardous incident;

h. Medical gas and vacuum systems, if applicable;

i. Communications systems; and

j. Essential services, such as kitchen and laundry services;

(13) Include a plan for alerting and managing staff in a disaster, and accessing Critical Incident Stress Management (CISM), if necessary;

(14) Include the management of residents, particularly with respect to physical and clinical issues to include:

a. Relocation of residents with their medical record including the medicine administration records, if time permits, as detailed in the emergency plan;

b. Access, as appropriate, to critical materials such as pharmaceuticals, medical supplies, food supplies, linen supplies, and industrial and potable water; and

c. How to provide security during the disaster;

(15) Identify a designated media spokesperson to issue news releases and an area where the media can be assembled, where they will not interfere with the operations of the facility;

(16) Reflect measures needed to restore operational capability with consideration of fiscal aspects because of restoration costs and possible cash flow losses associated with the disruption;

(17) Include an educational, competency-based program for the staff, to provide an overview of the components of the emergency management program and concepts of the ICS and the staff's specific duties and responsibilities; and

(18) If the licensee is located within 10 miles of a nuclear power plant and is part of the New Hampshire Radiological Emergency Response Plan (RERP), include the required elements of the RERP.

(f) The licensee shall conduct and document with a detailed log, including personnel signatures, 2 drills a year, at least one of which shall rehearse mass casualty response for the facility with emergency services, disaster receiving stations, or both, as follows:

(1) Drills and exercises shall be monitored by at least one designated evaluator who has knowledge of the -licensee's plan and who is not involved in the exercise;

(2) Drills and exercises shall evaluate program plans, procedures, training, and capabilities to identify opportunities for improvement;

(3) The licensee shall conduct a debriefing session not more than 72 hours after the conclusion of the drill or exercise. The debriefing shall include all key individuals, including observers, administration, clinical staff, and appropriate support staff; and

(4) Exercises and actual events shall be critiqued to identify areas for improvement. The critique shall identify deficiencies and opportunities for improvement based upon monitoring activities and observations during the exercise. Opportunities for improvement identified in critiques shall be incorporated in the licensee's improvement plan.

(g) For the purposes of emergency preparedness, each licensee shall have the following supplies of foods and water maintained on the premises based on the average daily census of residents and staff:

(1) Enough refrigerated, perishable foods for a 3-day period;

(2) Enough non-perishable foods for a 7-day period; and

(3) Potable water for a 3-day period.

(h) Each licensee shall have, in writing, a plan for the management of emergency food and water supplies required in (g) above, which includes:

(1) Assumptions for calculations of food and water supplies including maximum number of staff and residents, water source of supply, either tap or commercial, and expiration in months, tracking of supplies, and rotation of products, contracts and memorandums of understanding with food and water suppliers;

(2) Storage location(s); and

(3) Back-up supplies.

N.H. Admin. Code § He-P 803.28

Derived From Volume XXXIX Number 37, Filed September 12, 2019, Proposed by #12860, Effective 8/28/2019, Expires 8/28/2029.